What does a sports physical in a Primary Care Physician (PCP) clinic entail?

Sports Physical in a PCP Clinic

A sports physical in a primary care physician clinic is a preparticipation physical evaluation (PPE) that uses a systematic history and physical examination to identify cardiovascular and musculoskeletal conditions that could cause sudden cardiac arrest, sudden cardiac death, or injury during athletic participation. 1

Core Components

The PPE consists of two essential elements that PCPs must perform:

History Taking

The American Heart Association recommends a 14-point screening tool for athletic participation, while the American Academy of Pediatrics emphasizes 4 critical questions focused specifically on sudden cardiac arrest and sudden cardiac death risk 1:

The 4 AAP Questions (applicable to all children, not just athletes):

• Has the patient ever fainted, passed out, or had an unexplained seizure suddenly without warning, especially during exercise or in response to sudden loud noises (doorbells, alarm clocks, ringing telephones)? 1
• Has the patient ever had exercise-related chest pain or shortness of breath? 1
• Has anyone in the immediate family (parents, grandparents, siblings) or distant relatives (aunts, uncles, cousins) died of heart problems or had unexpected sudden death before age 50, including unexpected drownings, unexplained auto crashes where the relative was driving, or SIDS? 1
• Is the patient related to anyone with hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia, or anyone younger than 50 years with a pacemaker or implantable defibrillator? 1

Physical Examination

Cardiovascular assessment:

• Blood pressure measurement using appropriately sized cuff 1
• Cardiac auscultation for murmurs, clicks, or gallops 1
• Palpation of femoral pulses to exclude coarctation 1

Musculoskeletal examination: This is the highest-yield component for identifying conditions requiring restriction or follow-up 2, 3:

• Joint range of motion assessment 2
• Strength testing including hip abductors and flexors 3
• Evaluation for unilateral strength deficits 3
• Assessment of muscle tightness in upper and lower body 3
• Flexibility testing 3

Disposition and Follow-Up

Based on findings, the PCP assigns one of three dispositions 2:

1. Cleared for participation - No restrictions needed
2. Not cleared - Disqualification from sports (occurs in approximately 1.9% of athletes, with musculoskeletal problems being the leading cause at 43.4%) 2
3. Cleared with follow-up recommended - Abnormalities identified that don't preclude participation but require further evaluation (occurs in approximately 11.9% of athletes) 2

Critical Pitfalls to Avoid

Station-style examinations conducted in schools undermine the primary care relationship and are unlikely to provide quality comprehensive care 1. School or athletic team policies should not encourage supplanting routine well visits with sports physicals 1.

A positive response to any screening question should prompt cardiovascular evaluation at the PCP's discretion 1. Clinically significant cardiac abnormalities are found in only 0.37% of athletes, but missing these conditions can be fatal 2.

The musculoskeletal examination must be performed by qualified personnel, as it reveals the highest number of abnormalities requiring intervention 2, 3.

Timing and Frequency

The PPE should be performed at minimum every 3 years or on entry into middle or junior high school 1. However, it should ideally be integrated into annual preventive health visits rather than conducted as an isolated sports clearance 1.

Beyond Basic Clearance

The PPE should also assess 1, 3:

• Use of performance-enhancing drugs, anabolic-androgenic steroids, and stimulants (particularly caffeine in workout beverages) 1
• Body composition and excessive body fat (found in approximately 32% of athletes) 3
• Hypertension requiring lifestyle modification counseling 1